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Issue Overview

Continuum: Lifelong Learning in Neurology ® is designed to help practicing neurologists stay abreast of advances in the field while simultaneously developing lifelong self-directed learning skills.

Learning Objectives

Upon completion of the Continuum: Lifelong Learning in Neurology Headache issue, participants will be able to:

Explain the current concepts of the pathophysiology and diagnostic features of migraine and tension-type headache

Discuss the scientific rationale for acute and preventive migraine treatments

Identify the features of secondary headaches

Describe the unique features of and therapies for headaches in children

Recognize the pitfalls and predisposing features of medication overuse

Explain the scientific basis for the alternative and complementary migraine treatments

Core Competencies

The CONTINUUM Headache issue covers the following core competencies:

Patient Care

Medical Knowledge

Practice-Based Learning and Improvement

Interpersonal and Communication Skills

Professionalism

Systems-Based Practice

Disclosures

CONTRIBUTORS

Mark W. Green, MD, FAAN, Guest Editor

Professor of Neurology, Anesthesiology, and Rehabilitation Medicine and Director of Headache and Pain Medicine, Mount Sinai School of Medicine, New York, New York

*Dr Green has served as a speaker for Zogenix, Inc., and has performed malpractice reviews.

†All of the medications that Dr Green discusses for the treatment of headache in children are unlabeled except for almotriptan, which is approved for people aged 12 years and older, and rizatriptan, which is approved for people aged 6 years and older.

Shannon E. Babineau, MD

Assistant Professor of Neurology, Mount Sinai School of Medicine, New York, New York

*Dr Babineau reports no disclosure.

†All of the medications that Dr Babineau discusses for the treatment of headache in children are unlabeled except for almotriptan, which is approved for people aged 12 years and older, and rizatriptan, which is approved for people aged 6 years and older.

†Dr Brandes discusses the unlabeled use of medications for hormonal management and nonhormonal management of migraine in women, none of which are specifically US Food and Drug Administration approved for migraine.

Peter J. Goadsby, MD, PhD

Professor of Neurology, University of California, San Francisco, San Francisco, California

*Dr Graff-Radford serves as a member of the speakers’ bureau or as a consultant for Allergan, Inc.; MAP Pharmaceuticals, Inc.; Nautilus Pharma; NuPathe, Inc.; Pfizer, Inc.; and Zogenix, Inc. Dr Graff-Radford has served as an expert witness and has performed medical record review.

†Dr Graff-Radford discusses the unlabeled use of amitriptyline, selective serotonin-norepinephrine reputake inhibitors, and antiepileptic drugs for the treatment of temporomandibular disorders.

†Dr Tepper discusses the unlabeled use of medications in the treatment of medication-overuse headache for which there are no US Food and Drug Administration (FDA)-approved medications. OnabotulinumtoxinA, a biologic, is FDA approved for chronic migraine, and medication-overuse headache is a subset of chronic migraine.

*Dr Ward serves as a consultant for Cowan and Company and the US Department of Justice Vaccine Injury Compensation Program and has served as a medicolegal consultant for the State of New Hampshire and the University of Vermont. Dr Ward serves as editor of Headache Currents. Dr Ward served as a local investigator for a study sponsored by GlaxoSmithKline for which his institution received funding.

†Dr Ward discusses the unlabeled use of amitriptyline for migraine prevention.

Assistant Professor, Department of Neurology, University of Rochester Medical Center, Rochester, New York

*†Dr Kelly reports no disclosure.

Methods of Participation and Instructions for Use

Continuum: Lifelong Learning in Neurology® is designed to help practicing neurologists stay abreast of advances in the field while simultaneously developing lifelong self-directed learning skills. In Continuum, the process of absorbing, integrating, and applying the material presented is as important as, if not more important than, the material itself.The goals of Continuum include disseminating up-to-date information to the practicing neurologist in a lively, interactive format; fostering self-assessment and lifelong study skills; encouraging critical thinking; and, in the final analysis, strengthening and improving patient care.Each Continuum issue is prepared by distinguished faculty who are acknowledged leaders in their respective fields. Six issues are published annually and are composed of review articles, case-based discussions on ethical and practice issues related to the issue topic, coding information, and comprehensive CME and self-assessment offerings, including a self-assessment pretest, multiple-choice questions with preferred responses, and a patient management problem. For detailed instructions regarding Continuum CME and self-assessment activities, visit aan.com/continuum/cme.The review articles emphasize clinical issues emerging in the field in recent years. Case reports and vignettes are used liberally, as are tables and illustrations. Video material relating to the issue topic accompanies issues when applicable.The text can be reviewed and digested most effectively by establishing a regular schedule of study in the office or at home, either alone or in an interactive group. If subscribers use such regular and perhaps new study habits, Continuum's goal of establishing lifelong learning patterns can be met.

Accurate coding is an important function of neurologic practice. This contribution to CONTINUUM is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, evaluation and management coding, procedure coding, or a combination are presented, depending on which is most useful for the subject area of the issue.

EVALUATION AND MANAGEMENT CURRENT PROCEDURAL TERMINOLOGY CODING

Headache management requires significant face-to-face time between provider and patient, and the time spent in counseling and coordination of care may substantially prolong the outpatient visit. Fortunately, the time it takes to perform these activities is recognized and may increase reimbursement for the encounter if coded for properly. If time spent in counseling and coordination of care is greater than 50% of the total time of the visit, then the level of service based on the Evaluation and Management Current Procedural Terminology codes may be chosen according to time spent rather than fulfillment of the elements of the history or physical examination. The documentation must include the total time of the visit, the time spent in counseling and coordination of care, and a description of the medical necessity for the counseling and coordination of care.

Example: During a subsequent office visit with a patient with medication-overuse headache, the physician spends 30 out of a total of 45 minutes discussing control of medication overuse with the patient and his significant other. These times are documented, along with the medical necessity. At least 25 minutes of counseling is needed to qualify for a 99214 counseling visit. This code may be submitted for the visit with this documentation even though the history and examination elements have not been fulfilled.

ICD-9-CM CODING

Currently, International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes must be used for inpatient and outpatient physician billing. Always use the most specific code available. The documentation should include terms that are associated with the diagnosis code descriptions and an indication that this diagnosis was addressed during the encounter. Good documentation makes choosing a code easier. Persons with headache often have multiple diagnoses related to both the headache disorder and to coexistent conditions that impact headache or its treatment. The following points should be considered:

(1) Is the encounter for evaluation or treatment of a headache disorder or does the encounter address a complication due to comorbidity or treatment?

Patients may develop a medication reaction, such as tachycardia or chest pain, that needs to be coded. The diagnosis for the primary reason for the visit is coded first.

(2) Does the patient have a primary headache, a secondary headache, or both?

Patients with head trauma may have both posttraumatic headache and exacerbation of new-onset migraine.

(3) Does the patient have more than one type of primary headache?

Patients with migraine often have milder headaches that can be coded as tension-type headache. Patients with migraine with aura often have attacks of migraine without aura. Remember, you are coding headache attacks.

(4) What are the complications?

The ICD-9-CM recognizes the presence or absence of status migrainosus and intractability. The ICD-9-CM also equates “intractable” with “refractory.”

Example: A patient with an established diagnosis of migraine with and without aura returns to the office with a report of cervical pain during his nonaura migraine headache, which has been going on for 4 days. The following diagnosis codes would be submitted on the claim:

346.12 Migraine without aura, without mention of intractable migraine with status migrainosus

723.1 Cervicalgia

346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus

Example: A patient with an established diagnosis of migraine with and without aura returns to the office with a near-daily nonaura headache for the past 3 months and attacks of migraine 3 times per week. The patient uses triptans for each attack. The patient is counseled about overuse of triptans as a cause of the conversion to chronic migraine. The following diagnosis codes would be submitted on the claim:

346.71 Chronic migraine without aura, with intractable migraine, so stated, without mention of status migrainosus

339.3 Drug induced headache, not elsewhere classified

346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus

Try to be as specific as possible in coding coexistent diseases that are addressed during the visit. For example, the ICD-9-CM has special instructions for codes for hypertension and diabetes. If the hypertension is secondary, then two codes are required, one for the secondary hypertension and one for the cause. In order to choose a specific code for diabetes, it is important to document whether the diabetes is primary or secondary, type 1 or type 2, and controlled or uncontrolled. Medical records often do not include information regarding the control of hypertension or other disorders that are not being managed by the neurologist but that impact headache care. While coding nonspecific diagnoses is discouraged, there may be occasions when this is the best information available.

Example: During an outpatient visit for a patient with migraine with and without aura, the physician spends part of the visit evaluating coexistent conditions. This patient has a history of essential hypertension and obesity. Lifestyle change, diet, and medication are all discussed during the visit, as are the contraindications to certain medications. The diagnosis codes for this encounter are as follows:

346.00 Migraine with aura, without mention of intractable migraine without mention of status migrainosus

346.10 Migraine without aura, without mention of intractable migraine without mention of status migrainosus

ICD-10-CM CODING

The exact date of implementation of the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) in the United States is currently being reconsidered. The proposed date as of this article’s submission is October 1, 2014. ICD-10-CM codes are up to seven characters long and alphanumeric. The first character is always the letter corresponding to the chapter (system). The new codes are both more detailed and more logical. The new headache codes follow.

CONCLUSIONS

Patients often have more than one headache type; diagnose each type. With a secondary headache, diagnose both cause (eg, posttraumatic headache) and the headache phenotype (eg, migraine). Diagnose all comorbid and coexistent disorders.

ADDITIONAL RESOURCES

1. Centers for Medicare and Medicaid Services, National Center for Health Statistics. ICD-9-CM official guidelines for coding and reporting. www.cdc.gov/nchs/data/icd9/icdguide10.pdf. Updated October 1, 2010. Accessed May 4, 2012.